Kastrup A, Gröschel K
Department of Neurology, University of Göttingen, Göttingen, Germany.
Acta Chir Belg. 2007 Mar-Apr;107(2):119-28.
Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results. The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients. An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p < 0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41 ; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98). Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.
颈动脉粥样硬化疾病是缺血性中风的重要病因。颈动脉内膜切除术（CEA）是目前重度症状性颈动脉狭窄患者公认的标准治疗方法。然而，在过去几年中，颈动脉血管成形术和支架置入术（CAS）已成为该疾病一种潜在的替代性血管内治疗策略。事实上，受单中心研究和小型关键随机试验的积极结果推动，一些人甚至将CAS视为首选治疗方式，尤其是在可能属于外科手术高风险的患者中。然而，直接比较CAS与CEA的随机试验较少，且结果相互矛盾。本文旨在回顾关于这一问题的当前试验数据，并明确这些技术在两类重要亚组患者管理中的作用。一项对七项比较CEA与CAS的随机试验的最新荟萃分析表明，CAS与30天内任何中风或死亡风险显著增加相关（比值比[OR]为1.41，95%置信区间[CI]为1.07 - 1.87，p < 0.05）。聚焦于有症状颈动脉狭窄的患者时，CAS与CEA在治疗相关中风和死亡几率方面也存在显著差异（OR为1.41；CI为1.05至1.88，p < 0.05）。五项试验提供了30天内所有致残性中风和死亡的数据。血管内治疗组和手术组在30天致残性中风或死亡几率方面相似（OR为1.33，95% CI为0.89至1.98）。总体而言，这些数据并不支持对CAS盲目热衷以及广泛使用该手术治疗颈动脉狭窄。另一方面，仔细审视当前关于老年患者以及对侧颈动脉闭塞患者的文献清楚表明，CAS和CEA目前已具有互补作用。老年患者应优先接受CEA治疗，而在经验丰富的中心，CAS似乎是有症状颈动脉狭窄且对侧颈动脉闭塞患者的首选治疗方法。
